Tuesday, February 12, 2013

More Tales of Medical Excess: Cancer Screening and the Dangers of Check Box Medicine



A distressing study recently published in the Journal of General Internal Medicine once again demonstrates the remarkable proclivity of the US Health System to subject patients to excessive and harmful testing.

The investigators, led by Dr. David Haggstrom of Indiana University, asked primary care physicians if they would consider colon cancer screening for different types of patients, using patient vignettes.   While colon cancer screening is clearly indicated in many patients, in patients with very limited life expectancy, it is much more likely to cause harm than benefit. 

Haggstrom included in their vignettes the prototype of a patient who should not receive colon cancer screening:  A patient with incurable lung cancer.  Looking for a new early stage cancer in a person who already has advanced cancer is absurd.  Only bad things can come of this.  At a minimum, you are subjecting the patient to the cost and hassle of a test that has zero chance of helping them.  At its worst, you are subjecting a patient to the misery of the bowel prep and the risks of complications from a colonoscopy. 

So when the investigators asked, “what type of colon cancer screening would you do in a patient with unresectable lung cancer” one would hope the answer would be:  “Are you crazy?  I would of course do no screening at all”  However:

  • About 45% of physicians said they would screen a 50 year old with unresectable lung cancer
  • About 37% of physicians would screen a 65 year old with unresectable lung cancer
  • 25% of physicians would screen an 80 year old with unresectable lung cancer


Lest you think these survey responses do not reflect what happens in the real world, reread this GeriPal post from Alex Smith.  Unfortunately, screening for new cancers in persons with end stage cancer is all too common.

Certainly, the clinicians who recommended cancer screening were trying to do the right thing.  But their recommendation for colon cancer screening in a patient with advanced lung cancer may be the impact of check box medicine and performance measures run amok.  

Primary care clinicians are pressured to meet performance measures and targets for cancer screening, many of which don’t allow for individualized decision making.   Performance targets for cancer screening generally reward higher rates of screening rather than appropriate screening and informed decision making.  Performance measures almost always focus on doing more to the patient, but not necessarily for the patient.  Few performance measures reward physicians who protect their patients from inappropriate harmful care.  It is time to bring balance to performance measures. 

It should be noted that the clinicians who were surveyed often recommended less invasive forms of colon cancer screening to persons with lung cancer.  Rather than recommending screening colonoscopy, in most cases clinicians recommended fecal occult blood testing (FOBT).   As editorialist and GI endoscopist Dr. Douglas Robertson notes, this is an ultimately illogical choice, as any positive FOBT requires a colonoscopy for evaluation.  There is no logic in doing a FOBT if one is not prepared to do a colonoscopy if the FOBT is positive.  As noted by Robertson, 
"I have often been asked what to do next when a very old or very sick patient tested FOBT positive.  At this juncture, knowing the positive result, the decision becomes increasingly difficult.  The time to have the frank discussion about the real risks (eg sedation) and benefits of screening in those of advanced age or significant disease needs to occur before any screening is done, not after a noninvasive test suggests there may be a problem.”
There are many things a primary care clinician should be doing to help a patient with unresectable lung cancer.  But looking for a new cancer is not one of them.  It is hard to imagine that a clinician thinking about colon cancer can be thinking clearly about the extensive range of palliative services their patient really needs.  The greatest harm from cancer screening in these patients probably stems from the important services they are not getting because their true needs are not being recognized.


by: Ken Covinsky

2 comments:

Melinda said...

unbelievable. I worry it is this type of medicine that contributes to the rising cost of healthcare more than anything else. It is clearly what distinguishes us from other countries with similar life-expectancies and dramatically lower cost.

Mary Ann Bowling said...

I am writing because my mother passed away just over a year ago and I had to fight some siblings (some of whom are still not speaking to me) to get her into hospice care, the most humane and loving thing I felt I could do for her as my last act as her caretaker (and thankfully I had medical power of attorney). Since then I follow GeriPal. Mother was 92, suffering from severe congestive heart failure, diabetes, and stage 4 renal failure. Her mind was sharp,very little mental decline. Her primary physician told us it was a balancing act with the medications. We (the 3 of us)discussed dialysis when it might be needed (her cardiologist encouraged it) but she made it clear she didn't want that. She was ready to go. What tipped the balance was a stroke (rt middle cerebral artery) rendering her unable to move her one side and unable to swallow or speak. Not a single physician who attended her in the hospital spoke about hospice or even about her other medical issues,but rather kept ordering tests focused on the stroke and even suggesting therapy. I even dragged my brother to see her primary, hoping to enlighten him as to her frail condition. There's more to this but ultimately hospital doctors talked about a feeding tube but did not mention the complications to my family. My mother was drowning in fluids at this point, and I said "no" and asked for hospice care. If it had not been for her primary physician I wouldn't have had the knowledge or courage to make that decision and she would have suffered even more. Why did this happen? I think because physicians are afraid of lawsuits and because bringing up death can be difficult for anyone, including physicians. But if you keep pretending you can fix things, death can be ignored. I don't think the doctors are ignorant, just afraid.